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Key sources
The following summarized guidelines for the evaluation and management of hemorrhoids are prepared by our editorial team based on guidelines from the World Society of Emergency Surgery (WSES/AAST 2021), the American College of Gastroenterology (ACG 2021; 2014), the American Society of Colon and Rectal Surgeons (ASCRS 2018), and the American Academy of Family Physicians (AAFP 2018).


1.Diagnostic investigations

Clinical assessment
As per WSES 2021 guidelines:
Consider eliciting a focused medical history and performing a complete physical examination, including DRE, to rule out other causes of lower gastrointestinal bleeding in patients with suspected bleeding hemorrhoids.
Consider performing anoscopy as part of the physical examination in patients with complicated hemorrhoids, whenever feasible and well tolerated.
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  • Laboratory tests

  • Diagnostic imaging

2.Diagnostic procedures

Colonoscopy: as per WSES 2021 guidelines, consider performing colonoscopy in patients with complicated hemorrhoids if there is a concern for IBD or cancer arising from patient personal and family history or from physical examination.

3.Medical management

Pharmacotherapy: as per WSES 2021 guidelines, consider offering flavonoids to relieve symptoms in patients with complicated hemorrhoids.
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4.Nonpharmacologic interventions

Dietary modifications: as per ACG 2021 guidelines, advise dietary modifications consisting of adequate fluid and fiber intake and minimizing straining at defecation as first-line therapy in patients with symptomatic hemorrhoids.

5.Therapeutic procedures

Office-based procedures: as per ACG 2021 guidelines, perform office-based procedures, such as a rubber band ligation or infrared coagulation, sclerotherapy, and bipolar coagulation as alternatives, in patients with symptomatic grade I-II internal hemorrhoids failed medical therapy.

6.Surgical interventions

Early excision of thrombosed external hemorrhoids: as per ACG 2021 guidelines, perform either surgical excision or incision and evacuation of the thrombus in patients with acutely thrombosed external hemorrhoids if seen within the first 4 days.

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  • Excisional hemorrhoidectomy

  • Stapled hemorrhoidopexy

  • Hemorrhoidal artery ligation